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A successful treatment programs for osteoarthritis may involve a combination of therapies tailored to your needs, lifestyle and health. Osteoarthritis treatment has three general goals:

• control pain through drugs and other measures

• improve joint care through rest and exercise

• maintain an appropriate body weight and achieve a healthy lifestyle

In addition to the guidance of your primary health care professional, you may need care from a physical therapist, a rheumatologist (a physician who specializes in diagnosing and treating disorders that affect the joints, muscles, tendons, ligaments and bones) or a physiatrist (a physician who specializes in the diagnosis and management of injuries and diseases causing pain, loss of function and disability). Treatment plans often include the use of exercise, massage, heat, relaxation techniques, splints and braces and local injections to relieve pain.

Osteoarthritis treatment plans often include ways to manage pain and improve function. Such plans can involve exercise, rest and joint care, pain relief, weight control, medications, surgery, and nontraditional treatment approaches.

If you are diagnosed with osteoarthritis, you may be prescribed a variety of medicines to eliminate or reduce pain and to improve functioning. Health care professionals consider a number of factors when choosing medicines for their patients with osteoarthritis. Two important factors are the nature of the pain and a drug's potential side effects. You must use medicines carefully and tell your health care professional about any changes that occur.

The following types of medicines are commonly used in treating osteoarthritis:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). Many NSAIDs are used to treat osteoarthritis. Patients can buy some NSAIDs over the counter (for example, aspirin, ibuprofen, naproxen and ketoprofen). Other NSAIDs are available by prescription only. These drugs all reduce inflammation or swelling and relieve pain. However, each NSAID is a different chemical, and can have slightly different effects in the body.

NSAIDs can cause stomach irritation or affect kidney function and blood pressure. The longer you use NSAIDs, the more likely you are to have side effects, and the more serious those effects can be. Many other drugs cannot be taken with NSAIDs. NSAIDs are associated with serious gastrointestinal problems, including ulcers, bleeding and perforation. They should be used with caution in people over 65 and in those with any history of ulcers or gastrointestinal bleeding, congestive heart failure, renal insufficiency and hypertension.

In April 2005, the FDA issued a public health advisory that included important changes and additional warnings for prescription NSAIDs as well as for over-the-counter (OTC) NSAID products. Manufacturers of these products are being asked to revise their labels to include a boxed warning highlighting the potential for increased risk of cardiovascular (CV) events and gastrointestinal (GI) bleeding associated with their use. It's important to ask your health care professional for information about these recalls and safety information associated with pain relievers with your personal health history in mind.

Newer NSAIDs (called COX-2 specific inhibitors) inhibit an enzyme (COX-2), which triggers pain and inflammation, while sparing an enzyme called COX-1, which helps maintain the normal stomach lining. COX-2 specific inhibitors have been widely prescribed and effective prescription pain medications for rheumatoid arthritis, osteoarthritis and other pain-causing conditions, such as acute pain menstrual cramps. Celecoxib (Celebrex) is an example of a COX-2 specific inhibitor.

Rofecoxib (Vioxx), another drug in this category, was voluntarily withdrawn from the market in September 2004 by Merck, its manufacturer, after data from a study involving Vioxx indicated an increased risk for heart attack and stroke in patients participating in the study. Following the recall, the FDA began closely monitoring other drugs in this class of medications for similar side effects. In early April 2005, the FDA asked Pfizer, Inc., to withdraw valdecoxib (Bextra) from the market because the overall risk versus benefit profile for the drug was found to be unfavorable. Pfizer has agreed to suspend sales and marketing of Bextra in the U.S., pending further discussions with the agency.

FDA has also asked Pfizer to include a boxed warning about potential health risks in the Celecoxib (Celebrex) label. For more information about COX-2 specific inhibitors and the recalls visit: http://www.fda.gov.

If you think you are having an allergic reaction or have other severe or unusual symptoms while taking any NSAID, call your health care professional immediately.

• Acetaminophen (Tylenol). This analgesic and fever-reducer (antipyretic) is not an NSAID and does not reduce inflammation. It is less likely to irritate the stomach than NSAIDs. It is availability over-the-counter, low cost and mild side effects make it the drug of choice for treating mild to moderate arthritis pain, according to the American Pain Society. NSAIDs may be a better approach for some patients who experience pain at rest and pain at night-symptoms associated with significant inflammation.

Long-term use of acetaminophen may be associated with liver damage or inflammation of the kidneys (nephritis). Patients with liver disease and heavy alcohol drinkers should not use acetaminophen without first talking to a health care professional.

Health care professionals may prescribe several other medications for osteoarthritis. They include:

• Ultram or Ultracet (tramadol hydrochloride), which contains Tylenol.

• Rubs and sprays (for example, capsaicin cream) applied directly to the skin.

• Mild narcotic medications (opioids), which-while very effective-are potentially addictive and may have multiple side effects.

• Corticosteroids. These powerful anti-inflammatory hormones are made naturally in the body or produced synthetically. Corticosteroids are typically injected into affected joints to relieve pain temporarily. This is a short-term measure, not recommended more than two or three times per year.

Medicines used to treat osteoarthritis may have side effects, so it is important to learn about the drugs you are taking. Even nonprescription drugs should be reviewed. Certain patients may be at greater risk for side effects, such as those with a history of peptic ulcers or digestive tract bleeding, those taking oral corticosteroids or anticoagulants (blood thinners), those who smoke and those who consume alcohol. The risk of certain side effects in some osteoarthritis medications may be reduced by taking the drug with food. Some patients should avoid stomach irritants such as alcohol, tobacco and caffeine. Other medicines may be taken to protect the stomach lining by coating the stomach or blocking stomach acids. These measures help, but are not always completely effective.

Other options for relieving the pain and damage caused by osteoarthritis include:

• Viscosupplements: These medications replace hyaluronic acid (HA), a substance that helps lubricate the joints, which is lost in patients with osteoarthritis as a result of the disease. It is approved by the U.S. Food and Drug Administration for the treatment of knee pain in osteoarthritis patients who are unresponsive to nonpharmacologic measures and analgesic medications and who have significantly increased flares of inflammation or extensive inflammation in one or a few joints. One of two drugs, Hyalgan (hyaluronan) or Synvisc (Hylan) is injected directly into the joint to replace the hyaluronic acid and help the joint move freely. Many patients experience pain relief after a series of three to five injections. Researchers are testing whether hyaluronic acid can slow the progression of osteoarthritis.

• Physical or occupational therapy: Therapeutic interventions may include muscle strengthening, joint protection, modifying activities, pain management and education to preserve independence, encourage self-management and promote wellness.

• Surgery: A procedure called arthroscopic surgery has helped relieve the pain and disability of osteoarthritis in some people. With this type of surgical technique the interior of a joint can be visualized through the use of optic instruments, and surgery can be performed using direct visualization and miniaturized techniques. The procedure may be performed to resurface/smooth out bones (debridement), reposition bones or remove/flush out loose pieces of bone or cartilage from the joint (lavage).

Surgeons may replace affected joints with artificial joints called prostheses, which can last from 10 to 15 years or more. These joints can be made from metal alloys, high-density plastic and ceramic material and can be joined to bone surfaces by special cements. About 10 percent of these artificial joints may need revision. Surgeons choose the design and components of prostheses according to their patient's weight, sex, age, activity level and other medical conditions.

The decision to perform surgery depends on several factors-level of disability, intensity of pain, weight, interference with lifestyle, age and occupation, and other medical conditions. Currently, more than 80 percent of osteoarthritis surgery cases involve replacing the hip or knee joint. After surgery and rehabilitation, the patient usually feels less pain and swelling, and can move more easily.

Recently, the use of arthroscopic surgery of the knee for the management of osteoarthritis has come under increased criticism. Results of a clinical study published in the July 11, 2002 issue of the New England Journal of Medicine, and performed by investigators at Baylor College of Medicine and the Department of Veterans Affairs, have shown a significant placebo effect. In this unusual trial, patients with painful osteoarthritis were randomized and either surgically treated by arthroscopic debridement, arthroscopic lavage or a placebo (sham) procedure. Patients in all three groups had only moderate improvements in pain and function at two-year follow-up, indicating that the arthroscopic procedures were ineffective. Further investigations will likely be needed to confirm or refute these controversial findings.

• Weight loss: Weight loss can reduce stress on weight-bearing joints, limit further injury and results in less pain and better function. A dietitian can help you develop healthy eating habits and a nutritional plan to promote weight loss.

• Exercise: Exercise is a frequently used treatment for osteoarthritis, whether or not a patient is overweight. Exercise can improve mood and outlook, decrease pain, increase flexibility, improve the heart and blood flow, maintain weight and promote general physical fitness. It is also inexpensive and, if done correctly, has few negative side effects. The amount and form of exercise you can do will depend on which joints are involved, how stable the joints are, and whether a joint replacement has already been done.

Exercise can produce generalized improvement as well as specific effects. When it comes to osteoarthritis of the knee, the level of muscle strength in the thigh muscle (quadriceps) is very important. Strengthening this muscle can relieve symptoms and prevent more damage. Walking can result in better functioning and increased walking distance.

Ask your health care professional or physical therapist what exercises are best for you. Ask for guidelines on exercising when a joint is sore or if swelling is present. Also, check if you should use drugs, such as analgesics or anti-inflammatories, to make exercising easier, or use ice afterwards. An exercise plan should also include regularly scheduled rest. You should learn to recognize your body's signals, and know when to stop or slow down, in order to prevent pain caused by over-exercising.

• Supportive devices. Some individuals suffering from osteoarthritis pain use canes and splints to protect their joints and to take pressure off them. Splints or braces provide extra support for a weakened joint and keep the joint in proper position during sleep or activity. Splints must only be used for limited periods because joints and muscles need to be exercised to prevent stiffness and weakness. An occupational therapist or a health care professional can help fit you properly with a splint.

Alternative Therapies for Relieving Arthritis Pain

• Relaxation techniques: Some people with osteoarthritis find that relaxation techniques, such as deep breathing, guided imagery and visualization (where you focus on "seeing" pleasant pain-free scenes or activities in your mind) and stress reduction help provide some pain relief.

• Acupuncture: Acupuncture is an important component of traditional Chinese medicine that involves the insertion of thin needles at specific points, which are mostly along the body's nerve pathways, to improve health. According to the National Center for Complementary and Alternative Medicine at the National Institutes of Health, acupuncture may be useful as an adjunct treatment or an acceptable alternative treatment option for arthritis pain, when it is part of a comprehensive pain management program. Indeed, a recently completed clinical trial showed that acupuncture, when used along with conventional therapy, improved function and reduced pain in osteoarthritis of the knee. Individuals who want to use acupuncture should discuss their interest with their health care team, and only a licensed acupuncturist should be used. (See the "Acupuncture" topic at this Web site for more information.)

Nutritional supplements: Few studies have carefully evaluated the role of nutritional supplements in osteoarthritis. However, some studies do suggest that the supplements glucosamine and chondroitin sulfate provide a level of pain relief similar to the level of relief provided by NSAIDS such as aspirin and ibuprofen for individuals suffering from mild to moderate arthritis pain. There is some evidence, according to the Arthritis Foundation, that these nutritional supplements may slow cartilage damage caused by osteoarthritis.

Glucosamine and chondroitin sulfate are substances naturally produced by the body. The supplements are derived from animal tissue, specifically from crab, lobster and shrimp shells (glucosamine), and from animal (shark) cartilage (chondroitin).

Neither product is approved by the FDA for relieving osteoarthritis pain; nor does the FDA regulate supplements, as it does over-the-counter medications and prescription drugs. Side effects associated with these supplements include increased intestinal gas and softened stools. If you experience these problems, you might want to try another supplement brand before you stop using them altogether.

Vitamins C, D and E as well as beta carotene may slow the progress of osteoarthritis, but, again, more research is needed to confirm these claims.

Products and reports about nutritional supplements claiming to provide pain relief should be viewed with caution until more studies can be conducted. Discuss your interest or questions about such products and reports with your health care professional.

• Transcutaneous electrical nerve stimulation (TENS): TENS is the application of electrical stimulation from a small device to the skin for pain relief. According to the American Pain Foundation, TENS seems to work by blocking pain messages to the brain and by modifying pain perception. To relieve some arthritis-related pain, the TENS device is positioned to direct the mild electric pulses to nerve endings beneath the skin on or near the painful area affected by arthritis. According to the American Pain Society, TENS is non-invasive, inexpensive and safe and easy to use. TENS machines cost between $80 and $800. (The inexpensive units are fine.) You can wear them during the day and turn them off and on as needed for pain control-they may provide some pain relief.

• biofeedback. Biofeedback is a way to enhance a body signal so that one is aware of something that usually occurs at a level below consciousness. An electronic device provides information about a body function (such as heart rate) so that the person using biofeedback can learn to control that function. Biofeedback can help people with arthritis learn to relax their muscles. In this case, an electronic device amplifies the sound of a muscle contracting, so the arthritis patient knows that the muscle is not relaxed. The therapy is typically learned with the help of a health care professional and then may be practiced at home, either with the use of a biofeedback machine once the patient has mastered the technique, or without one.